Provider First Line Business Practice Location Address:
5201 S DORCHESTER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60615-4107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-301-8202
Provider Business Practice Location Address Fax Number:
773-947-9633
Provider Enumeration Date:
01/05/2009